Nokea
The nurse is caring for a client with a diagnosis of hyperemesis gravidarum. Which laboratory finding is most likely to be present?
- A. Metabolic alkalosis
- B. Hyponatremia
- C. Hypokalemia
- D. All of the above
Correct Answer: D
Rationale: Hyperemesis gravidarum causes prolonged vomiting leading to metabolic alkalosis (loss of stomach acid) hyponatremia (electrolyte loss) and hypokalemia (potassium loss). All are likely findings in severe cases.
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The nurse is admitting a client with folic acid deficiency anemia. Which of the following questions is most important for the nurse to ask the client?
- A. Do you take aspirin on a regular basis?'
- B. Do you drink alcohol on a regular basis?'
- C. Do you eat red meat?'
- D. Have your stools been normal?'
Correct Answer: B
Rationale: Aspirin does not affect folic acid absorption. Folic acid deficiency is strongly associated with alcohol abuse. Because folic acid is a coenzyme for single carbon transfer purines, calves liver or other purines are the meat sources. Folic acid does not affect stool character.
The nurse is caring for a client with a history of a pulmonary embolism who is receiving Lovenox (enoxaparin). The nurse should monitor the client for:
- A. Bleeding
- B. Hypertension
- C. Tachypnea
- D. Fever
Correct Answer: A
Rationale: Enoxaparin, a low-molecular-weight heparin, increases bleeding risk, requiring monitoring for signs like bruising or hematuria. Hypertension, tachypnea, and fever are not primary concerns.
Which of the following physician's orders would the nurse question on a client with chronic arterial insufficiency?
- A. Neurovascular checks every 2 hours
- B. Elevate legs on pillows
- C. Arteriogram in the morning
- D. No smoking
Correct Answer: B
Rationale: Neurovascular checks are a routine part of assessment with clients having this diagnosis. Elevation of the legs is contraindicated because it reduces blood flow to areas already compromised. Arteriogram is a routine diagnostic order. Smoking is highly correlated with this disorder.
The client is admitted with a diagnosis of preterm labor. Which symptom is most characteristic?
- A. Uterine contractions
- B. Fetal macrosomia
- C. Maternal fever
- D. Painless vaginal bleeding
Correct Answer: A
Rationale: Uterine contractions (regular frequent) are the hallmark of preterm labor occurring before 37 weeks. Fetal macrosomia maternal fever and painless bleeding are not characteristic.
A burn victim's immunization history is assessed by the nurse. Which immunization is of priority concern?
- A. Oral poliovirus vaccine
- B. Inactivated poliovirus vaccine
- C. Tetanus toxoid
- D. Hepatitis B vaccine
Correct Answer: C
Rationale: Tetanus toxoid prevents tetanus. Tetanus is transmitted through contaminated wounds.